102. Reduction, in this case, is attended in general with but little
difficulty. The patient, lying on his back, is held under the
arm-pits, and by the upper part of the pelvis, by assistants who
make counter-extension in this way, without being obliged to pass,
as recommended by the Academy of Surgery, a strap under the affected
thigh (30). Another assistant makes extension, according to the
method formerly described (29), drawing the point of the fragment
very gradually in the direction opposite to that which it has taken
in becoming displaced, and making the thigh at the same time rotate
a little on its own axis. This gentle rotation renders success more
certain.
103. If things be properly arranged, a slight effort is sufficient to
bring the separated fragments into contact and to restore to the limb
its natural form; for, as I have already observed (86), a facility of
reduction is even one of the characters of this fracture. But it is
very difficult for art to maintain permanently what she easily effects
at the time of reduction, and on this account, our curative processes
are oftentimes insufficient.
104. These processes may be considered under three classes, according
as they relate 1st, to position; 2dly, to bandages; 3dly, to the forms
of apparatus for making permanent extension.
In the first class must be included the method of Foubert, employed
in ancient times, according to Louis, and which consists in placing
the patient on a horizontal plain, while the limb is secured by
simple splints, and the foot by a kind of shoe. But in a short time
the muscular action, to which no resistance whatever is made, draws
the lower fragment upwards, while the weight of the body pushes the
pelvis downwards, and along with it the superior fragment. Hence a
new reduction, the effect of which is again immediately destroyed as
at first. Thus are new displacements succeeded by new replacements
throughout the whole course of the treatment.
105. This method, almost universally adopted in latter times, and
approved of by Louis, was in vogue at the hospital of Charity, when
Desault entered it. Ought we then to be surprised, that the fracture
was considered as incurable? Here indeed the plainest and most
important indication is evidently disregarded. Nothing to retain the
fragments in apposition, nothing to prevent them from being constantly
moved. Does not the method of Foubert very closely resemble those
experiments, in which, the bone of an animal is broken intentionally,
and then to prevent a reunion and form an artificial joint, the
fragments are kept in constant motion?
106. Will any better success attend the method of securing the leg, as
Dalechamp recommends, to the foot of the bed? In such a case the trunk
and the pelvis glide down along the inclined plain made by the pressure
of the nates (14), and hence a constant cause of the shortening of the
limb.
107. The second class of curative means, includes different forms of
apparatus simply retentive. Pare, Petit, and Heister, recommend, as
most useful, the _Spica_ of the groin.[26] But what effect can this
produce? What force applied in that part can keep the lower fragment
down, and the pelvis up, secure the immobility of the limb, and prevent
its rotation outwards? If the bandage be tight, it will compress the
muscles unequally, make them contract, and thus become the cause of
a contraction or shortening of the limb. In some respects, there is
more advantage to be derived from the tin case lined with cloth on its
inside, which Fabricius of Hilden applied to the external part of the
thigh; a method which has been renewed since his time, by certain
celebrated practitioners of Germany; from the pasteboard case proposed
by Duverney as a substitute for that of tin; from the retentive
plaster[27] of Buffle employed likewise by Arnaud; and from the splints
adopted by most practitioners. But can these means, (so differently
varied in form, yet still the same in their action), while they prevent
displacement laterally or in the cross-direction of the bone, prevent
it also in the longitudinal direction, which latter ought to be the
principal object in view? Will they make any resistance to the muscular
action? See what has been already said on splints, bandages, &c.
(89 ... 95).
[26] _Le Spica de l’aine._ TRANS.
[27] (_L’ecusson._) The literal meaning of this word is an
escutcheon, or a coat of arms. But when used in surgical language,
it signifies a retentive or strengthening plaster. Such I conceive
its meaning to be in the present instance. TRANS.
108. The insufficiency of these forms of apparatus, arises from their
not being constructed with a proper view or reference to the general
principle that ought to be observed in the treatment of every fracture;
namely, that the means intended to prevent displacement, ought to be
founded on the causes that produce it. But, these causes here, are,
1st, The action of the muscles which draw the lower fragment upwards:
2dly, The weight of the body which pushes the pelvis downwards: 3dly,
The weight and direction of the foot and leg, which tend to carry the
toes outwards by a rotatory motion. Hence, the threefold indication or
end of every apparatus, is, 1st, To keep the body of the bone down:
2dly, To retain the pelvis up: and 3dly, To secure the foot nearly in
a right line with the leg.
109. The first consideration leads us naturally to the second. The
means destined to fulfil this three-fold indication, must be constant
in their action, since the causes which they have to combat act without
remission. Hence the necessity of an apparatus for permanent extension.
See what has been said on the nature of this expedient (46 ... 51), on
the different modes of effecting it (52 ... 57), and particularly on
the mode pursued by Desault (58 ... 70).
110. The mechanism of his apparatus for permanent extension is the
same here as in fractures of the body of the bone. The limb is secured
against a strong splint, to the two ends of which two rollers, running
one from the pelvis, and the other from the foot, are firmly tied. The
first of these rollers holds the pelvis up, and the second draws the
foot down: hence the two first indications are fulfilled. The third
is also fulfilled by the extension of the limb, which prevents its
rotation outwards, by means of the outside splint, which passing beyond
the sole of the foot keeps it immoveable.
111. The bandage of strips and compresses, which in fractures of the
body of the bone, are previously applied round the limb, and oppose in
some measure its motions laterally, are here entirely useless. Being
all indeed applied on the lower fragment, what purpose could they
answer towards fixing it against the upper one? They could do nothing
but compress the muscles, and by that means diminish their power
of contraction: but extension alone produces this effect. Desault
rejected the bandage altogether, and contented himself with the use of
splints and bolsters, as appears from the following case reported by
Couteau.
CASE VI. Maria Nof, as she was running on the ice, in the severe winter
of 1788, slipped, and falling on the great trochanter, fractured the
neck of the os femoris. She was immediately carried to the Hotel-Dieu,
where the signs formerly mentioned (60 ... 66) disclosed at once the
nature of her disease. The shortening of the limb was less than in
ordinary cases.
The apparatus was applied in the following manner. The junk-cloth, the
body-bandage, and the bits of tape, were laid on the bed, in the order
already mentioned (60): the patient was then placed in such a manner
that the affected thigh corresponded exactly to the middle of them.
The reduction being effected, the two splints were applied, one on the
external and the other on the internal side of the limb; on each side,
and along the anterior part of the thigh, the bolsters were laid: three
bits of tape for the leg, four for the thigh, and the body-bandage
for the pelvis, served to secure the splints. One end of a roller,
which had been previously fixed on the upper side of the foot, passing
through the mortise on the external splint, and being tied to the other
end which passed through the hollow or notch, produced extension,
while counter-extension was made by means of another roller directed
obliquely from the tuberosity of the ischium over the superior part of
the same splint, which it drew downwards. This was the same apparatus
formerly described (60 ... 66), except as to the bandage of strips, the
compresses, and the anterior splint, which running only from the fold
of the groin, had no effect in retaining the fragments.
The treatment was simple. No general disease of the system existing,
the patient returned, in a few days, to her usual regimen. Being
visited every day, the apparatus was frequently tightened; and was
renewed six times at different intervals.
A bilious disposition shewed itself on the seventeenth day. This
was removed by an emetic given in solution, and after this nothing
remarkable occurred. On the fifty-second day the state of the parts
was examined. The consolidation was almost accomplished; by the
sixtieth day it was complete, and the patient was discharged a few days
afterwards, experiencing only a slight degree of lameness.
§ XVII.